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Childbirth

By the end of the ninth month of pregnancy, most women are tired of being pregnant; both parents are eager to
start a new phase of their lives. Most couples find the actual process of birth to be an exciting and positive
experience.

Choices in Childbirth

Many couples today can choose the type of practitioner and the environment they want for the birth of their
child. A high-risk pregnancy is probably best handled by a specialist physician in a hospital with a nursery, but
for low-risk births, many options are available.

Most babies in Canada are born in hospital. Parents can choose to have their baby delivered by a physician (an
obstetrician or family practitioner) or by a registered midwife. In Canada, most babies are delivered by an
obstetrician. The number of babies delivered by family physicians is decreasing, while the number delivered by
midwives is increasing.

Midwives are health care providers who care for women and their babies during pregnancy, labour, delivery, and
the postpartum period. Midwifery is regulated in Canada by provincial and territorial authorities. Midwives who
are registered with these authorities use the title registered midwife (RM) or sage-femme (SF), and they are
legally allowed to practise midwifery.

Some mothers-to-be are accompanied in the delivery room by a labour companion, called a doula. A doula is a
woman who has either been through childbirth or has extensive experience with birth. She stays with the
labouring woman continuously and provides emotional and tangible support, information, and advocacy.
Supportive labour companions may improve labour progress by reducing maternal anxiety. Studies show that the
presence of a knowledgeable doula can shorten the duration of labour, increase the rate of spontaneous vaginal
birth, and reduce the use of narcotic painkillers, forceps delivery, and Caesarean birth.

It's important for prospective parents to discuss all aspects of labour and delivery with their physician or
midwife beforehand so they can learn what to expect and can state their preferences. For more information, see
the Critical Consumer box.

Critical CONSUMER
Making a Birth Plan

A variety of birth situations can have positive physical and psychological outcomes. Parents should choose what
is appropriate for their medical circumstances and what feels most comfortable to them. Prospective parents
should discuss their preferences in the following areas with their physician or midwife:

1. Who will be present at the birth? The father? Friends? Children and other relatives? Will young siblings
be allowed to visit the mother and new baby? What are the hospital/centre policies in terms of visitors and
number of people present at the birth?

2. What type of room will the mother be in during labour, delivery, and recovery?

3. What types of tables, beds, or birthing chairs are available? What type of environment can be created for
the birth? Can specific music be played?

4. Will the mother receive any routine preparation, such as an enema, intravenous feeding, or shaving of the
pubic area?

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5. What is the policy regarding food and drink during labour? Will the mother have the option of walking
around or taking a shower or bath during labour?

6. Under what circumstances does the physician or midwife administer drugs to induce or augment labour?
The use of these drugs tends to change the course of labour and carries a small risk.

7. How is the fetus monitored during labour? According to the SOGC, it is best to monitor the baby at
regular intervals during labour; however, some circumstances require continuous monitoring.

8. Under what circumstances will an episiotomy, an incision at the base of the vaginal opening, be
performed? Are any steps taken to avoid it? According to the SOGC, there is no reason to perform routine
episiotomies.

9. Under what circumstances will forceps or vacuum extraction be used? In some cases of fetal distress, the
use of forceps or vacuum extraction may be necessary to save the infant's life, but some authorities believe
these techniques are overused.

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10. What types of medications are typically used during labour and delivery? Some form of anaesthetic is
usually administered during most hospital deliveries, as are hormones that intensify the contractions and
shrink the uterus after delivery. Different types of anaesthetics, including short-acting narcotics, regional
nerve blocks, and local anaesthetics, may be available; each has different effects on the mother and the
fetus.

11. Under what conditions or circumstances does the physician perform a Caesarean section?

12. Who will catch the baby as she or he is born? Who will cut the umbilical cord?

13. What will be done to the baby immediately after birth? What kinds of tests and procedures will be done on
the baby, and when?

14. How often will the baby be brought to the mother while they remain in the hospital or birthing centre? Can
the baby stay in the mother's room rather than in a nursery? This practice is known as rooming-in.
Research shows that rooming-in is best for babies and mothers. It gives the mother and baby an
opportunity to bond, and the risk of infection is decreased for babies who room-in with their mother when
compared with babies who stay in a nursery.

15. How will the baby be fedby breast or bottle? Will feeding be on a schedule or on demand? Is there
someone with breastfeeding expertise available to answer questions if necessary?

Labour and Delivery

The birth process occurs in three stages (see Figure 12.8). Labour begins when hormonal changes in both the
mother and the baby cause strong, rhythmic uterine contractions to begin. These contractions exert pressure on
the cervix and cause the lengthwise muscles of the uterus to pull on the circular muscles around the cervix,
creating effacement (thinning) and dilation (opening) of the cervix. The contractions also pressure the baby to
descend into the mother's pelvis, if it hasn't already. The entire process of labour and delivery usually takes
between 2 and 36 hours, depending on the size of the baby, the baby's position in the uterus, the size of the
mother's pelvis, the strength of the uterine contractions, the number of prior deliveries, and other factors. The
length of labour is generally shorter for second and subsequent births.

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Click here for a description of Figure 12.8 Birth: Labour and Delivery.

FIGURE 12.8
FIGURE 12.8 Birth: Labour and Delivery
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The First Stage of Labour

The first stage of labour averages 13 hours for a first birth, although wide variation exists among women. It
begins with cervical effacement and dilation and continues until the cervix is completely dilated (10
centimetres). Contractions usually last about 30 seconds and occur every 1520 minutes at first, more often later.
The prepared mother relaxes as much as possible during these contractions to allow labour to proceed without
being blocked by tension. Early in the first stage, a small amount of bleeding may occur as a plug of slightly
bloody mucus that blocked the opening of the cervix during pregnancy is expelled. In some women, the amniotic
sac ruptures and the fluid rushes out; this is sometimes referred to as the water breaking.

The last part of the first stage of labour, called transition, is characterized by strong and frequent contractions,
much more intense than in the early stages of labour. Contractions may last 6090 seconds and occur every 13
minutes. During transition the cervix opens completely, to a diameter of about 10 centimetres. The head of the
fetus usually measures 910 centimetres; thus once the cervix has dilated completely, the head can pass through.
Many women report that transition, which normally lasts about 3060 minutes, is the most difficult part of
labour.

The Second Stage of Labour

The second stage of labour begins with complete cervical dilation and ends with the delivery of the baby. The
baby is slowly pushed down, through the bones of the pelvic ring, past the cervix, and into the vagina, which it
stretches open. The mother bears down with the contractions to help push the baby down and out. Some women
find this the most difficult part of labour; others find that the contractions and bearing down bring a sense of
relief. The baby's back bends, the head turns to fit through the narrowest parts of the passageway, and the soft
bones of the baby's skull move together and overlap as it is squeezed through the pelvis. When the top of the
head appears at the vaginal opening, the baby is said to be crowning.

As the head of the baby emerges, the physician or midwife will remove any mucus from the mouth and nose,
wipe the baby's face, and check to ensure that the umbilical cord is not around the neck. With a few more
contractions, the baby's shoulders and body emerge. As the baby is squeezed through the pelvis, cervix, and
vagina, the fluid in the lungs is forced out by the pressure on the baby's chest. Once this pressure is released as
the baby emerges from the vagina, the chest expands and the lungs fill with air for the first time. The baby will
still be connected to the mother via the umbilical cord, which is not cut until it stops pulsating. The baby will
appear wet and often is covered with a cheese-like substance. The baby's head may be oddly shaped at first,
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because of the moulding of the soft plates of bone during birth, but it usually takes on a more rounded
appearance within 24 hours.

The Third Stage of Labour

In the third stage of labour, the uterus continues to contract until the placenta is expelled. This stage usually
takes 530 minutes. It is important that the entire placenta be expelled; if part remains in the uterus, it may cause
infection or bleeding. Breastfeeding soon after delivery helps control uterine bleeding because it stimulates the
secretion of a hormone that makes the uterus contract.

The baby's physical condition is assessed with the Apgar score, a formalized system for assessing the baby's
need for medical assistance. Heart rate, respiration, colour, reflexes, and muscle tone are individually rated with
a score of 02, and a total score between 0 and 10 is given at one and five minutes after birth. A score of 710 at
five minutes is considered normal. Most newborns are also tested for at least 30 rare disorders that can be treated
early, decreasing future health problems for the child. In Canada, many newborns are screened for such
disorders, but the specific disorders screened for vary across provinces and territories.

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Pain Relief During Labour and Delivery

Women vary in how much pain they experience in childbirth. First babies are typically the most challenging to
deliver, as the birth canal has never stretched to this extent before. It is recommended that women and their
partners learn about labour and what kinds of choices are available for pain relief. Childbirth preparation courses
are a good place to start, and communicating with the obstetrician or midwife is essential to assess the
approaches that will be available. Breathing and relaxation techniques, such as Lamaze or Bradley, have been
used effectively, and they are often modified by the labouring women to be even more effective. Forms of
hypnosis can also be used.

The most commonly employed medical intervention for pain relief is the epidural. This procedure involves
placing a thin plastic catheter between the vertebrae in the lower back. Medication that reduces the transmission
of pain signals to the brain is given through this catheter. Local anaesthetic drugs are given in low concentration
to minimize weakening of the leg muscles so that the mother can effectively push during the birth. The amount
of medication given is quite low and does not accumulate in the baby or interfere with the baby's transition after
birth. The mother is awake and is an active participant in the birth.

Women can also elect to have narcotics, such as morphine or demerol, given for pain relief during labour, but
these medications usually provide less pain relief than the epidural and, if given shortly before the birth, can
cause the baby to be less vigorous at birth. Local anaesthesia is available for repair of any tear or episiotomy if
the mother has not used an epidural for the labour.

Caesarean Deliveries

In a Caesarean section, the baby is removed through a surgical incision in the abdominal wall and uterus.
Caesarean sections are necessary when a baby cannot be delivered vaginallyfor example, if the baby's head is
bigger than the mother's pelvic girdle or if the baby is in an unusual position. If the mother has a serious health
condition, such as high blood pressure, a Caesarean may be safer for her than labour and a vaginal delivery.
Caesareans are more common among women who are overweight or have diabetes. Other reasons for Caesarean
delivery include abnormal or difficult labour, fetal distress, and the presence of a dangerous infection, such as
herpes, that can be passed to the baby during delivery. A growing number of Caesareans are performed on low-
risk mothers; researchers hope further analysis will help determine if the trend is due to patient choice, physician
choice, or a combination of the two.

According to Statistics Canada, the Caesarean delivery rate in Canada is the highest it has ever been, increasing
from 5 percent of deliveries in the 1960s, to 20 percent in the 1980s, to more than 25 percent today. Like any
major surgery, Caesarean sections carry some risk and should be performed only for valid medical reasons rather
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than for convenience. The SOGC encourages deliveries without interventions, such as Caesarean sections,
unless medically necessary. Women who have Caesarean sections can remain conscious during the operation if
they are given a regional anaesthetic, and the father or another person the mother chooses may be present.

Repeat Caesarean deliveries are also very common. In 20112012, about 82 percent of Canadian women who
had had one child by Caesarean had subsequent children delivered the same wayan increase of 9 percent from
73 percent in 20012002. Although the risk of complications associated with a vaginal delivery after a previous
Caesarean delivery is low, there is a small (1 percent) risk of serious complication to the mother and baby if the
previous uterine scar opens during labour (uterine rupture). For this reason, women and their doctors may
choose to deliver by elective repeat Caesarean.

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QUESTIONS FOR CRITICAL THINKING AND REFLECTION

If you are a woman, what are your views on labour and delivery options? If you have a child in the future, which
facility, delivery, and pain management options do you think you would prefer? If you are a man, what are your
views on participating in delivery? What role would you want to play?

The Postpartum Period

The postpartum period, a stage of about three months following childbirth, is a time of critical family
adjustments. Parenthood begins literally overnight, and the transition can cause considerable stress.

Following a vaginal delivery, mothers usually leave the hospital within one to three days (after a Caesarean
section, they usually stay three to five days). Uterine contractions will occur from time to time for several days
after delivery, especially during nursing, as the uterus begins to return to its pre-birth size. It usually takes six to
eight weeks for a woman's reproductive organs to return to their pre-birth condition. She will have a bloody
discharge called lochia for three to six weeks after the birth.

Within the first few days after birth, a baby will undergo newborn screening for certain rare disorders as noted
above. The baby's headif somewhat pointed following a vaginal deliverywill become more rounded within
a few days. It takes about a week for the umbilical cord stump to shrivel and fall off. Regular infant checkups for
health screenings and immunizations usually begin when the infant is only a few weeks old.

Breastfeeding

Video: Breastfeeding Concepts

Click here to view a transcript of this video

In 20112012, about 89 percent of Canadian mothers breastfed their infants after delivery. This is a slight
increase from 85 percent in 2003. Lactation, the production of milk, begins about three days after childbirth.
Before that time (sometimes as early as the second trimester), colostrum is secreted by the nipples. Colostrum
contains antibodies that help protect the newborn from infectious diseases and is also high in protein.

Health Canada and the Canadian Paediatric Society recommend breastfeeding exclusively for six months, then
in combination with solid food up to two years of age, and then for as long after that as a mother and baby
desire. Exclusive breastfeeding means that a baby is only fed breast milk and no other liquids or solids. In 2011
2012, 26 percent of Canadian mothers breastfed exclusively for at least 6 months, compared to 17 percent in
2003. Figure 12.9 illustrates the increase in breastfeeding rates from 2003 to 20112012 across Canada. Human
milk is perfectly suited to the baby's nutritional needs and digestive capabilities, and it supplies the baby with
antibodies. Breastfeeding decreases the incidence of infant ear infections, allergies, anemia, diarrhea, and
bacterial meningitis. Preschoolers who were breastfed as babies are less likely to be overweight, and school-age

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children who were breastfed are less anxious and better able to cope with stress. Breastfeeding even has a
beneficial effect on blood pressure and cholesterol levels later in life.

Click here for a description of Figure 12.9 Rates of Exclusive Breastfeeding for Six Months or More, 2003 and
2011-2012.

FIGURE 12.9
FIGURE 12.9 Rates of Exclusive Breastfeeding for Six Months or More, 2003 and 20112012
Source: Statistics Canada, Canadian Community Health Survey, 2003 and 2011-2012,
http://www.statcan.gc.ca/pub/82-624-x/2013001/article/11879/c-g/c-g-03-eng.htm

Breastfeeding is beneficial to the mother, as well. It stimulates contractions that help the uterus return to normal
more rapidly, contributes to post-pregnancy weight loss, and may reduce the risk of ovarian cancer, breast
cancer, and post-menopausal hip fracture. Nursing also provides a sense of closeness and emotional well-being
for mother and child. For women who want to breastfeed but who have problems, help is available from support
groups, books, or a lactation consultant.

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For some women, physical problems, such as tenderness or infection of the nipples, can make breastfeeding
difficult. If a woman has an illness or requires drug treatment, she may have to bottle-feed her baby because
drugs and infectious agents may show up in breast milk. Breastfeeding can be restrictive, making it especially
difficult for working mothers. Employers rarely provide nursing breaks, so bottle-feeding or the use of a breast
pump (to express milk for use while the mother is away from her infant) may be the only practical alternatives.
Bottle-feeding also allows the father or other caregiver to share in the nurturing process. Both breastfeeding and
bottle-feeding can be part of loving, secure parentchild relationships.

When a mother doesn't nurse, menstruation usually begins within about 10 weeks. Breastfeeding can prevent the
return of menstruation for six months or longer because the hormone prolactin, which aids milk production,
suppresses hormones vital to the development of mature eggs. However, ovulationand pregnancycan occur
before menstruation returns, so breastfeeding is not a reliable contraceptive method; if a woman wants to avoid
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pregnancy, she should use a more reliable method. If the mother becomes pregnant while still nursing, she needs
to make sure that she is receiving adequate nutrition, because the energy requirement for both breastfeeding and
gestating is immense. With proper counselling, breastfeeding can continue until near delivery.

Breastfeeding can enhance the bond between mother and child. Health Canada and the Canadian Paediatric
Society recommend breastfeeding exclusively for six months and then in combination with solid food up to 2
years of age and beyond.
QUICK STATS

51% of women in Canada exclusively breastfed their babies for at least 4 months in 20112012.

Statistics Canada, 2013

Postpartum Depression

Many women experience fluctuating emotions during the postpartum period as hormone levels change. The
physical stress of labour, as well as dehydration, blood loss, and other physical factors, lowers the woman's
stamina. About 5080 percent of new mothers experience baby blues, characterized by episodes of sadness,
weeping, anxiety, headache, sleep disturbances, and irritability. A mother may feel lonely and anxious about
caring for her infant. About 59 percent of new mothers experience postpartum depression, a more disabling
syndrome characterized by despondency, mood swings, guilt, and occasional hostility. Rest, sharing feelings and
concerns with others, and relying on supportive relatives and friends for assistance are usually helpful in dealing
with mild cases of the baby blues or postpartum depression, which generally lasts only a few weeks. If the
depression is serious, professional treatment may be needed. Some men also seem to get a form of postpartum
depression, characterized by anxiety about their changing role and feelings of inadequacy. Both mothers and
fathers need time to adjust to their new roles as parents.

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Attachment

Another feature of the postpartum period is the development of attachmentthe strong emotional tie that grows
between the baby and the adult who cares for the baby. Parents can foster secure attachment relationships in the
early weeks and months by responding sensitively to the baby's needs. Parents who respond appropriately to the
baby's signals of gazing, looking away, smiling, and crying establish feelings of trust in their child. They feed
the baby when she is hungry, for example; respond when she cries; interact with her when she gazes, smiles, or
babbles; and stop stimulating her when she frowns or looks away. A secure attachment relationship helps the
child develop and function well socially, emotionally, and mentally.

For most people, the arrival of a child provides a deep sense of joy and accomplishment. However, adjusting to
parenthood requires effort and energy. Talking with friends and relatives about their experiences during the first
few weeks or months with a baby can help prepare new parents for the period when the baby's needs may

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require all the energy that both parents have to expend. But the pleasures of nurturing a new baby are substantial,
and many parents look back on this time as one of the most significant and joyful of their lives.

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